Boerhaave syndrome (spontaneous esophageal perforation) most commonly occurs at which anatomical location and involves which mechanism?

• A At the pharyngoesophageal junction (Killian's triangle) due to straining
• B Mid-esophagus at the level of the aortic arch due to pulsatile erosion
• C At the diaphragmatic hiatus due to herniation and strangulation
• D Left posterolateral wall of the lower esophagus, 3–5 cm above the EGJ, due to sudden rise in intraesophageal pressure ✓

Explanation

Boerhaave syndrome results from sudden forceful vomiting causing a rapid rise in intraesophageal pressure against a closed cricopharyngeus. The characteristic location is a longitudinal tear on the left posterolateral wall of the lower esophagus, approximately 3–5 cm above the gastroesophageal junction, where the esophageal wall is thinnest and lacks external reinforcement. This leads to left-sided pleural effusion (hydropneumothorax) and mediastinitis. Killian's triangle is the site of Zenker's diverticulum, not Boerhaave.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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